Check a Business Name in Indiana by jsm40037

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									                  APPLICATION FOR LICENSE
                  TO OPERATE A HOME HEALTH AGENCY
                  State Form 4008 (R8/6-06)
                  Indiana State Department of Health-Div ision of Acute Care
                  (Pursuant to IC 16-27-1-7 and 410 IAC 17- 10-1)
                  Approv ed by State Board of Accounts, 2006


                                                              Divi sion of Acute Care Use Only

       Date Received (month, day, year ) ____________________ Date Approved (month, day, year) ___________________

            All questions on this application must be answered completely in printed or typed script. Supporting documentation must be
             attached to application. Complete all sections on this application. AN INCOMPLETE OR ILLEGIBL E APPLICATION WILL BE
             RETURNED WIT HOUT BEING PROCESSED.
            License and/or approval renew al must be obtained annually.
            This application and the license, and/or approval which m ay be issued as a result, are neither assignable nor transferable.
            Previous receipt of a certification is not a guarantee that a license and/or approval w ill be issued.
            A non-refundable application fee in the amount of $250.00 must accompany this application. No license and/or approval shall be
             issued without receipt of this fee.

Please Type or Print Legibly
                                                              SECTION I - TYPE OF APPLICATON
Application (check appropriate item)

       Change of Ownership (Anticipated date of Sale/Purchase/Lease)__________________                                  New Facility
       Submit a dated and signed copy of the bill of sale, lease or other document of transfer

                          Medicare and Medicaid                        Medicare                    Medicaid                      State License Only

                                                          SECTION II - IDENTIFYING INFORMATION
A. Practice Location (name of facility d/b /a of direct owner)
If the d/b/a is different from the direct owner/entity the d/b/a must be registered with the State of Indiana Office of the Secretary of State. Submit
”Certificate of Doing Business Name” document signed by the State of Indiana, Office of the Secretary of State that list owner/entity name and d/b/a.
Name of Agency


Street address                                                                                                                            P.O. Box


City                                                                                     County                                           Zip code +4


Telephone number                        Fax number                             Facility’s offic e hours (i.e. 8:00 a.m. – 4:00 p.m. Monday - Friday)
(      )                                (     )

E- mail address                                                          Web address


B. Mailing Address (if different from practice location)
Street address                                                                                                                            P.O. Box

City                                                                                     State                                            Zip code +4


C. Licensee/Ownership Information (direct owner of the facility d/b /a)
The owner/entity as registered with the State of Indiana, Office of Secretary of State (SOS) and appears on the Articles of Incorporation, etc. signed by
the (SOS). Submit Articles of Incorporation, etc. from the State of Indiana, Office of Secretary of State (SOS) and SS-4 form or other comparable
document from the Internal Revenue Service (IRS) that reflects the owner/entity name, d/b/a if applicable and EIN number.
Licensee/Owner/Entity of the facility (d/b/a) (The owner’s name as registered with the SOS and appears on the document)


Street address                                                                                                                            P.O. Box


City                                                                                     State                                            Zip code+4


Telephone number                        Fax number                             EIN Number (sub mit docu mentation to validate)      Fiscal year end date (mm/dd)
(      )                                (     )



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D. Branch Offices (as defined in 410 IAC 17-9-5) (applicable for change of ownership only – do not complete if initial application)
Does the Agency have branches ?            Yes        No
If yes, please provide the name, address, and telephone number of each branch location. (use additional sheet if necessary)
                             Name                                                    Address (street address/city/zip)                   Telephone Number




E. Types of home health services to be provided (check all that apply)

                             Home Health Aide                            Medical Social Services                     Nursing
                             Occupational Therapy                        Physical Therapy                          Speech Therapy
                             Other (List all) _____________________________________________________________

                      _____________________________________________ ________________________________________


F. Types of personal services to be provided

Do you provide services as performed by a personal services agency under IC 16-27-4?                 Yes       No If yes, check the services provided.

Homemaker Services                                      Companion Type Services                                 Assistance With Cognitive Tasks

    Shopping         Laundry                                  Transportation      Letter writing                    Managing finances      Planning activities

    Cleaning         Seasonal chores                          Mail reading        Escort services                   Making decisions

Attendant Care Services as defined under 16-27-1 and 16-27-4                         An y other personal services performed that does not require
                                                                                     under state law: a license, certification, registration, or permit

                                                                                     ___________________________________________________
Attendant Care Services
                                                                                     ___________________________________________________
                                                                                     ___________________________________________________
                                                                                     ___________________________________________________


G. Provider Based


Is this facility a hospital and/or provider based facility?   (owned by a separate licensed entity) Not applicable for freestanding facility.


    Yes         No (If yes, provide Medicare number)




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                                                             SECTION III – STAFFING
A. Administrator (as defined in 410 IAC 17-9-2)
Name (enter full name)




1.       Submit a current copy of the administrator’s resume with complete employment history with month/year of employment and reason for leaving.
         The resume must reflect one (1) year) supervisory/management experience in healthcare. The supervisor/manager must be responsible
         for the day-to-day operation of a healthcare entity with the authority to evaluate and to appoint and terminate employees. Submit a current
         copy of any applicable license as defined in 410 IAC 17-9-15, such as a nurse, and a copy of a current limited criminal history check
         from the Indiana State Police.



2.       List post secondary education and health related experience


         ______________________________________________________________________________________________________________


         ______________________________________________________________________________________________________________




3.       Has the administrator ever been convicted of any criminal offense relating to, or any way associated with, a dependent population?
            Yes        No     (If yes, state on a separate sheet the facts of each case completely and concisely.)


4.       Has the administrator’s license (if applicable) ever lapsed, been suspended or revoked?           Yes       No
         (If yes, explain on a separate sheet of paper the place, date and agency initiating action, action taken and reason.)




B. Alternate Administrator
Name (enter full name)




1.       Submit a current copy of the administrator’s resume with complete employment history with month/year of employment and reason for leaving.
         The resume must reflect one (1) year) supervisory/management experience in healthcare. The supervisor/manager must be responsible
         for the day-to-day operation of a healthcare entity with the authority to evaluate and to appoint and terminate employees. Submit a current
         copy of any applicable license as defined in 410 IAC 17-9-15, such as a nurse, and a copy of a current limited criminal history check
         from the Indiana State Police.



2.       List post secondary education and health related experience


         ______________________________________________________________________________________________________________


         ______________________________________________________________________________________________________________




3.       Has the alternate administrator ever been convicted of any criminal offense related to, or in any way associated with, a dependent population?
            Yes         No (If yes, state on a separate sheet the facts of each case completely and concisely.)

4.       Has the alternate administrator’s license (if applicable) ever lapsed, been suspended or revoked?          Yes        No
         (If yes, explain on a separate sheet of paper the place, date and agency initiating action, action taken and reason.)




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C. Nursing Supervisor (Supervising Physician or Registered Nurse)
Name (enter full name)


Indiana license number (please include a copy of license with application)


Education (Name of School of Nursing or School of Medicine)


Degree                                                                                       Year graduated


List of post-secondary and home health care experience



          ______________________________________________________________________________________________________________

          ______________________________________________________________________________________________________________

          ______________________________________________________________________________________________________________

          ______________________________________________________________________________________________________________



Has the Director of Nurses (nursing supervisor) license ever lapsed, been suspended or revoked?             Yes       No
(If yes, explain on a separate sheet of paper the place, date and agency initiating action, action taken and reason.)


Submit a current copy of the nursing supervisor’s resume w ith complete employment history , month/year of employment and reason for leaving. The
resume must reflect one (1) year supervisory/management experience in healthcare and two (2) years nursing experience. The supervisor/manager
must be responsiblefor the day-to-day operation of a healthcare entity with the authority to evaluate and to appoint and terminate employees. Submit
current copy of Physician or RN license and a copy of a current limited criminal history check from the Indiana State Police.

D. Alternate Nursing Supervisor (Supervising Physician or Registered Nurse)
Name (enter full name)


Indiana license number (please include a copy of license with application)


Education (Name of School of Nursing or School of Medicine)


Degree                                                                                         Year graduated


List of post-secondary and home health care experience



          ______________________________________________________________________________________________________________

          ______________________________________________________________________________________________________________

          ______________________________________________________________________________________________________________

          ______________________________________________________________________________________________________________



Has the Alternate Director of Nurses (alternate nursing supervisor) license lapsed, been suspended or revoked?             Yes   No
(If yes, explain on a separate sheet of paper the place, date and agency initiating action, action taken and reason.)

Submit a current copy of the nursing supervisor’s resume w ith complete employment history, month/year of employment and reason for leaving. The
resume must reflect one (1) year supervisory/management experience in healthcare and two (2) years nursing experience. The supervisor/manager
must be responsiblefor the day-to-day operation of a healthcare entity with the authority to evaluate and to appoint and terminate employees. Submit
current copy of Physician or RN license and a copy of a current limited criminal history check from the Indiana State Police.




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                                     SECTON IV - OWNERSHIP AND CONTROLLING INTEREST
A. Ownership Information (officers/directors/managing agents/managing employees of the home health agency)
List names and addresses of individuals or organizations having direct or indirect ownership or controlling interest of five percent (5%)
or more in the applicant entity. Indirect ownership interest is an entity that has an ownership interest in the applicant entity. Own ership
in any entity higher in a pyramid than the applicant constitutes indirect ownership. (use additional sheet if necessary)
                        Name                               Business Address (street address/city/state/zip code)             EIN Num ber




B. Type of Ownership (applicable for change of ownership only) (check appropriate type of ownership )


              Asset Purchase Agreement                       Assignment of Interest                          Lease


              Merger                                         New Partnership                                 Sale


              Termination of Lease                           Transfer of Asset Agreement                     Other ______________________

Submit a bill of sale or comparable document, which includes corporation/owner(s) name(s) and buyer/seller signature(s) and effective date
of transaction.

C. Type of Entity (check appropriate item)
For Profit                                              NonProfit                                       Government

     Individual                                              Church Related                                  State
    * Partnership                                            Individual                                      County
    ** Corporation                                          * Partnership                                    City
    *** Limited Liability Company                           ** Corporation                                   City/County
     Sole Proprietorship                                    *** Limited Liability Company                    Hospital District
     Other (specify) _____________________________           Other (specify) _____________________           Federal

_____________________________________________           _____________________________________                Other (specify) ________________

_____________________________________________           _____________________________________           ________________________________



*If a Limited Partnership, submit a copy of the “Application For Registration” and “Certificate of Registration” signed by the State of
Indiana Office of Secretary of State.


**If a Corporation, submit a copy of the “Articles of Incorporation” and “Certificate of Incorporation” signed by the Indiana Secretary of
State. If a foreign Corporation, submit a copy of the “Certificate of Authority to do Business in the State of Indiana“ signed by the State
of Indiana Office of Secretary of State.


***If a Limited Liability Company, submit a copy of the “Articles of Organization” and the “Certificate of Organization” signed by the State
of Indiana Office of Secretary of State.

If the doing business name (d/b/a) is different from the direct owner’s name submit a “Certificate of Assumed Business Name” signed
by the State of Indiana Office of the Secretary of State.




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                                              SECTION V - DISCLOSURE OF APPLICANT ENTITY
A. Directors/Officers/ Partners/Managing Agents/Managing Employees (Direct owners)
List all individuals (persons) associated with the applicant entity and indicate the individual’s title (i.e. officer, director, member, partner,
president, vice president, secretary, etc). If the applicant is a partnership, list the name and title of each partner or the name and title of all
individuals associated with each entity that forms the partnership. If the applicant is a Lim ited Liability Company, list t he name and title for
all individuals associated with each member entity that forms the Limited Liability Company. (Use additional sheet if necessary.)
                                                                                                                Business Address
                   Officer or Partner Name                                Title
                                                                                                        (street address/city/state/zip code)




B. Licensure/Operating History


1.        Have the ow ners or managers of the agency operated any agency w ithin Indiana or any other state w hic h had a record of denial of licensure
          or of operation w ith less than a full license (i.e. probationary, provisional, denial of annual license renewal, etc .)
              Yes        No      (If “Yes”, Provide name of each agency on a separate sheet and explain the facts completely and concisely.)


          a.        If any applications have been denied or w ithdrawn, so state with a full explanation. (Use additional sheet if necessary.)

          b.        If any license has been granted, state the date granted and expiration date. (Use additional sheet if necessary.)


2.        Are there any individuals or organizations having direct or indirect ownership or control interest in the agency of five perc ent (5%) or more
          who have been convic ted of a criminal offense related to the involvement of such persons or organiz ations in any of the programs es tablished
          by Titles 18, 19 or 20 (Medicare or Medicaid)?
              Yes        No    (If “Yes”, List each person or entity on a separate sheet and explain relationship.)


3.        Are there any directors, officers, agents or managing employees of the agency who have ever been convicted of a criminal offense related to
          the involvement of such persons or organiz ations in any of the programs established by Titles 17, 18, 19 or 20 (Medicare or Medicaid)?
               Yes     No     (If “Yes”, List each person on a separate sheet and explain the facts completely and concisely.)


                                              SECTION VI – MANAGEMENT (Managing Company)
The name and address of the corporation, association, or other company this is responsible for the management of the home health agency, and the
name and address of the chief executive offic er and the chairman or equivalent position of the governing body of that corporation, association, or other
legal entity responsible for the management of the home health agency. (If not applicable, please state not applicable.)
A. Name and address of corporation, association, or other company that is responsible for the management of the home health agency

                          Name of Corporation                                        Address of Corporation (street address, city, state ZIP code)




B. Name, address and title of the chief executive offic er and the chairman or equiv alent position of the governing body of the managing company

                       Name                                        Address (street address/city/state/zip code)                           Title




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                                             SECTION VII - CERTIFICATION OF APPLICATION



The undersigned hereby makes application for a license to operat e a home health agency in the State of Indiana, and in
support of this application, represents and shows that the owners and operators are of reputable and responsible
character, are able to comply with the home health agency statutes, IC 16 -27, and the rules promulgat ed thereunder, 410
IAC 17 and will operate and maintain this agency in accordance with those rules.

I hereby certify that the operational policies of the home health agency will not provide for discrimination based upon race,
color, creed or national origin.

I swear or affirm under the penalty of perjury that all statements made in this application and any attachments theret o are
correct and complet e and that I will comply wit h all laws, rules and regulations governing the licensing of home healt h
agencies in Indiana.

                APPLICANT’S SIGNATURE OR SIGNATURE OF THE APPLICANT’S AUTHORI ZED AGENT
                                         SHOULD APP EAR BELOW.

If signed by any individual (e.g., the administrator) ot her than indicated in section IV.A or V.A. of this application, an
affidavit must be submitted with the application, affirming that said persons has been given the power to bind the
applicant/licensee.




Name of authoriz ed representative (typed)                                                   Title



Signature of authoriz ed representative                                                              Date (month, day, year)




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           SECTION VIII – DOCUMENTATION THAT MUST BE SUBMITTED WITH THE LICENSE APPLICATION


1.   A non-refundable license fee of two hundred fifty dollars ($250) made payable to the Indiana State Department of Health and mailed w ith
     application to:

                                              INDIANA STATE DEPARTMENT OF HEALTH
                                                  ATTENTION: CASHIER, 2 ND FLOOR
                                                          P.O. Box 7236
                                                   INDIANAPOLIS, INDIANA 46207


2.   A non-refundable license fee of two hundred fifty dollars ($250) is according to Home Health Statue IC 16-27-1-7 (B) and Home Health
     Rules 410 IAC 17-10-1 (c) Licensure as shown below.

     Home Health Statue:
     IC 16-27-1-7
     READS.....
     Sec. 7. The state department shall adopt rules under IC 4-22-2 to do the following:
       (1) Protect the health, safety, and welfare of patients.
       (2) Govern the qualifications of applicants for licenses.
       (3) Govern the operating policies, supervision, and maintenance of service records of home health agencies.
       (4) Govern the procedure for issuing, renewing, denying, or revoking an annual license t o a home health agency, including the following:
          (A) The form and content of the license.
          (B) The collection of an annual license fee of not more than two hundred fifty dollars ($250) that the state department
               may waive.
        (5) Exempt persons who do not provide home health services under this chapter.
          As added by P.L.2-1993, SEC.10. Amended by P.L.212-2005, SEC 11

     Home Health Rules
     410 IAC 17-10-1 Licensure
     READS:
     410 IAC 17-10-1 Licensure
     Authority: IC 16-27-1-7
     Affected: IC 12-17-15-3; IC 16-20; IC 16-22-8; IC 25-22.5
     Sec.1. (a) No home health agency shall: (1) be opened; (2) be operated; (3) be managed; (4) be maintained; or (5) otherwise conduct
     business; without a license issued by the department.

     (b) A license is required for any home health agency providing care in Indiana where the parent agency is located in a state other than
     Indiana. The home health agency must: (1) be authorized by the secretary of state to conduct business in Indiana; and (2) have a branch
     office located in Indiana.

     (c) Application for a license to operate a home health agency shall be: (1) made on a form provided by the department; and
     (2) accompanied by a nonrefundable fee of two hundred fifty dollars ($250).


3.   Copies of the administrator’s and alternate administrator’s current Indiana license (any applicable license if you are an administrator or
     heath care professional as defined in 410 IAC 17-9-15, such as a nurse), resume and limited criminal history check. Copies of the nursing
     supervisor and alternate nursing supervis or current Indiana Registered Nurse license, resume and a limited criminal history check. Submit
     a legible wallet size copy of the current Indiana license(s) that shows the expiration date.
         A Limited criminal history check must be obtained from the Indiana State Police Central Repository.


4.   Artic les of Incorporation and/or other documents from the Indiana Secretary State Offic e of the Secretary of State.
         If a limited Partnership, submit a copy of the “Application for Registration” and “”Certific ate of Registration” signed by the State of Indiana
          Office of the Secretary of State.
         If a Corporation, submit a copy of the “Articles of Incorporation” and Certif icate of Incorporation” signed by the State of Indiana Office of
          the Secretary of State.
         If applicant is an out of state corporation (foreign corporation), submit a copy of the “Certific ate of Authority to do Business in the State of
          Indiana” signed by the State of Indiana Office of the Secretary of State.
         If a Limited Liability Company, submit a copy of the “Articles of Organization” and the “Certificate of Organization” signed by the State of
          Indiana Office of the Secretary of State.
         If the “doing business as” (d/b/a) name is different from the corporation’s (dir ect owner’s ) name submit “Certificate of Assumed Business
          Name” that list the corporation/owner’s name and d/b/a name signed by the State of Indiana Office of the Secretary of State.


5.   Submit a SS-4 or other comparable document from the Internal Revenue Service (IRS) that reflects the owner/entity name, d/b/a if applicable
     and EIN number.



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